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• 0 STATE ID NUMBER 00000038814002 <br /> CONTAINER CONSTRUCTION <br /> E. ( 1 Ol RUBBER LINED ( ) 02 ALKYD LINING ( ) 03 EPDXY LINING ( 1 04 PHENOLIC LINING ( 1 05 GLASS LINING <br /> [ ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( 1 01 POLYETHLENE WRAP ( ) 02 VINYL WRAPPING [ l 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( ) 05 NONE <br /> ( 1 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. (CHECK PIPING: <br /> BOX(ES) [ 01(� 04 PRESSURELEO )IPE 02 05 SUCTION CONCRETE-LINED 06EUNKNOWNTREN 7H 07 NONE <br /> 3 GRAVITY <br /> NONE <br /> B (CHECK OUND APPROPRIATE PIPING:APPROPRIATEBOXES) ( CW 04 PRESSURELED ) 05 SUCTION CONljR 06EUNKNOWNTR ENC) 07(NONE <br /> VII LEAK DETECTION GRAVITY <br /> ((0�� <br /> (X1 01 VISUAL (X) 02 STOCK INVENTORY ( 1 04 VAPOR SNIFF WELLS f l 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( l 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( ) <br /> 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( 1 02 ( ] 03 <br /> ( ) <br /> 01 ( 1 02 ( 1 03 <br /> ( ) <br /> 01 ( 1 02 ( ) 03 <br /> ( ) <br /> 01 f 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 f ) 03 <br /> ( 1 01 f ) 02 ( 1 03 <br /> ( ] <br /> 01 t 1 02 [ 1 03 <br /> ( 1 Ol f 1 02 ( ) 03 <br /> ( 1 <br /> 01 ( 1 02 ( ) 03 <br /> * CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> ISCONTAINER LOCATED ON AN AGRICULTURAL FAR�( ) YES (X) 02 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> PERSON FILING (SIGNATUREPHONE W/AREA CODE <br /> FOR LOCAL AGENCY SE ONLY q <br /> S/ COUNTY CODE <br /> ADMINISTRATING AGENCY F D( CITY CODE <br /> AIV �l0 to I A/ L O ( I F F L-T H <br /> PHONE W/AREA CODE <br /> CONTACT PERSON, ^ ^ G L_?_0'--co <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT IO # <br /> 0 YES ( 1 02 NO <br /> PAGE 2 <br /> HSC04-070185 (10/18/85) <br />